GPs in Belgium are becoming increasingly confident about referring patients for euthanasia, new research suggests, as in September 2016 the country approved the first death of a child under its laws.

The latest study has divided Australian experts amid renewed clamour for a national vote on the issue. Opponents claim that the findings provide fresh evidence of a slippery slope of widening justification for euthanasia, and of the ineffectiveness of safeguards to avoid abuse of the legislation. Supporters, by contrast, emphasise that the overall rate of deaths is still very low, and say that euthanasia is finding a natural place in palliative care.

The study, a decade-long review of reported euthanasia deaths in Belgium, found that there had been a “broadening of the previously narrow interpretation of the legal criteria,” with an increasing rate of cases involving people without terminal illnesses.

The study showed that the number of reported euthanasia deaths in Belgium climbed from 235 in 2003 to 1807 by 2013. However, the actual numbers are likely to be twice as high, the authors noted, as only about half of euthanasia deaths are thought to be reported to authorities under mandatory notification provisions.

Most reported cases involved people with cancer and those under 80 years. However, over the decade, the rate of euthanasia deaths increased significantly in other categories, including people aged over 80 years and those with a disease other than cancer. In 2013, 66 cases involved people who suffered psychologically but not physically.

Under Belgian law, patients requesting euthanasia must consult with a second independent physician. In 2003, this was most often a specialist palliative care physician or a disease or organ specialist. However, by the second half of the decade this was usually another GP.

“I am concerned by the reduction in referral to palliative care doctors and specialists in the euthanasia approval process, as GPs are less likely to know whether or not the suffering can be alleviated – the keystone of the act,” she said.

“This is a weakening of the due process of the act and suggests that the ‘safeguards’ are seen more as a barrier to be overcome than an opportunity to improve life to the extent that euthanasia is no longer necessary.”

The study found a strong cultural divide in the uptake of euthanasia in Belgium, where 60% of the population speak Dutch and 40% French. Most of euthanasia cases were reported in Dutch (79–87%), and Dutch cases were more likely to involve patients not likely to die in the foreseeable future.

The authors said that these cultural differences “suggest that euthanasia legislation does not have a predetermined effect on medical end-of-life practice and that social and cultural elements also influence its development.”

However, Dr Best pointed to the “enormous” influence of the Dutch media in Belgium, where “euthanasia is framed as a positive choice, even in the absence of life-limiting illness, and there is praising of ‘brave’ doctors who do the deed”.

In Flanders, where most people speak Dutch, the Federation of Palliative Care Flanders has endorsed euthanasia as part of the palliative care continuum.

“I have spoken to colleagues from Belgium who say that they have become involved in the euthanasia pathway in order to increase the number of people who actually try palliative care, but there is considerable moral injury occurring among the practitioners as it is opposed to the traditional ends of medicine,” Dr Best told MJA InSight.

“When a person is euthanised it impacts carers, friends and families, and influences society as a whole that killing a fellow human being is acceptable and that suicide is a legitimate way to deal with hardship,” she said.

Professor Margaret Somerville, professor of bioethics at the University of Notre Dame Australia’s School of Medicine, raised similar concerns.

“Euthanasia is a revolution – a seismic shift – in our foundational values as a society, not an incremental evolution in them,” she said. “As health care professionals become accustomed to euthanasia as routine practice, they lose a sense of the horror of inflicting death.”

Professor Somerville said the Belgian experience showed that “once legalised, euthanasia cannot be contained or controlled”.

Such fears were quickly panned by Professor Michael Ashby, director of palliative care at the Royal Hobart Hospital.

“All these so-called ‘slippery slope’ arguments are flawed and deeply tactical in my view by opponents of assisted dying,” he said. “The Belgian experience shows that assisted dying and palliative care can not only co-exist but enhance each other.

“The Belgian public are responding appropriately to the availability of assistance to die,” he said. “We know that it is the long deterioration with chronic diseases, especially in people over 80 years old, and in chronic neurodegenerative and related conditions, including for younger people, that demand is strong and growing.”

Professor Ashby said the Belgian model was “a very good one” for Australia.

Dying with Dignity NSW President Dr Sarah Edelman was also positive about the Belgian findings.

“Among those who accessed assisted deaths, the increase in the proportion of patients who died at home and of those who accessed palliative care (34%–39%) is a positive development,” she told MJA InSight.

Dying with Dignity NSW does not advocate a “Belgian model” for Australia; it only supports euthanasia for mentally competent adults with unrelievable suffering from a terminal or advanced incurable illness.

“Assisted dying regimes generally place a high value on human life by increasing autonomy of the individual and respecting their rights, as well as showing increased levels of compassion and a desire to minimise suffering,” Dr Edelman said.

Liz Callaghan, CEO of Palliative Care Australia, said that the organisation believed palliative care did not include euthanasia, which is consistent with the World Health Organization’s definition.

The experience in Belgiium,Holland and US states such as Oregan where voluntary medical assisted dying for terminally ill people has been legal for over 15 years shows there are none of the problems opponents try to use to oppose the legalisation of medically assisted dying.
In fact only between 1% and 4% of deaths use the law but the overwhelming majority of people in these countries and indeed in Australia support the availability of this legal option because none of us know how much suffering we will have to face when we are dying and palliative care cannot relive all suffering..

I must say, I was horrified by what I read. 66 people because of mental illness (my interpretation of ‘psychologically but not physically’)? In my experience, people who are chronically suicidal have borderline personality disorder. Such people elicit strong emotions, such as wanting to care, or fear, or anger. They also use their suicidal state as a central means to communicate their distress. That is, if they feel particularly bad one day, they discuss it in terms of being suicidal, rather than , say, interpersonal or coping terms. To assist such people to die is to collude with them (although I appreciate that in saying that I might be presuming what I am trying to prove). My sense is that being approved for euthanasia would be powerfully validating to them. On the other hand, maybe it would remove the worry that clinicians have that such patients are suicidal, and allow them to deal with other things.

One person and the GP? That is really not a second opinion at all, because the GP and the patient could have already arrived at their view together. No devil’s advocate, against euthanasia, at all, for many people. And society applauding it. I wonder what, if anything, happened to the suicide rate in the community (nothing I suppose, otherwise it would have been big news).

I do not know why people do not use the principle of double effect to deal with intractable suffering in people with a terminal illness. In that instance, if suffering cannot be relieved, you add drugs until it is, and then, if the person stops breathing, so be it. All this discussion about euthanasia, and none about the current (probably) legal principle that governs the issue. Google ‘double effect’ and australian law, if you want.

I am a psychiatrist who is against Euthanasia for our community, and especially that Medicine should be integrally involved in this. However, there seems a strong community request in developed countries for Euthanasia, and I suspect this political momentum will be quite powerful in a society scared and protected from death and suffering. So I have been thinking about another proposal to put before society.

If society wants to move in this direction, why can’t lawyers be in charge of the process? I think this will focus the community mind more about what is involved, and will integrally deal with the legal aspects, which as well as ethical aspects, are vitally important, and part of the controversy. Surely the Government can set up an End of Life Court where decisions will be made about any active death, either assisted suicide or euthanasia. This court may be situated near an End of Life Institute, in which End of Life Technicians would kill people in a humane way, with family or friends around them if desired. Doctors may be called to give evidence where there is any uncertainty in the court, but where the person and family/friends are all agreed, the process could be swift. The court would need to be able to act quickly if required (similar to mental health hearings), and be relatively informal in its ambience. End of Life Technicians could travel in the community to people’s homes, or when allowed, to health care facilities – and those cases could be facilitated in court using video court presence.

What do others think? Could this be a way to deal with the issues, but not have doctors as a central component. Those doctors who are keen to do so could become End of Life Technicians, but work under a legal umbrella. I am not convinced that doctors will be good killers without adequate training.

Throughout my career as a palliative medicine physician, I have accompanied more than 30,000 patients on their journey towards death. I regard that journey as a profound mystery, to be approached with awe. For each patient I have provided “medical assistance in dying” so that each patient can “die with dignity”. However, I have never provided any treatment with the primary intention of ending the patient’s life. I find it deceptive that the terms “medical assistance in dying” and “death with dignity” are used as euphemisms for mercy killing and physician assisted suicide.
One of Australia’s most prominent euthanasia advocates, Dr Rodney Syme, has pointed out that there is a legal alternative: fasting. In his book, “a good death” on page 182, he says “it requires minimal or no medical help, but good nursing, particularly mouth care is essential. There is constant accompaniment, conversation and music, with simple sedation as required. . . . .this process is perhaps twice as common in the Netherlands as medical euthanasia, because many of these people were frail and elderly, and did not qualify for euthanasia, or were denied it.”

I agree with Bill Pring. This is an area where doctors have no expertise. Leave it to lawyers and politicians and perhaps a panel of “experts” to determine when someone’s life is “not worth living”. Doctors believe in principle, as well as by training, that life is a good, while disease and premature death are bad, and our professional expertise is on maximizing patients opportunity for health. There is actually already a group in the community which are already trained in euthanasia, and practice it regularly – vets. Indeed, many in the community who advocate euthanasia for patients cite the good work vets do putting animals out of their misery. So surely if the community really wants euthanasia, they would want it provided by the most experienced practitioners. Which set me wondering, would vets be happy to start euthanizing humans? If not, why not? Is it something contrary to their training and professional ethos? It is definitely contrary to the professional ethos and training of medical doctors. I say leave healing in the hands of doctors. Put the burden (or if you prefer, the celebration) of euthanasia in the hands of bureaucrats – or retired governors general, since some among them apparently already know how to identify the “unproductive burdens” the community should be relieved of.

The AMA has just published an article about the Belgian assisted dying law experience, which it says “splits Aussie experts.” But the AMA report indicates that at least one, Dr Megan Best, gets her facts fundamentally wrong.

“I am concerned by the reduction in referral to palliative care doctors and specialists in the euthanasia approval process, as GPs are less likely to know whether or not the suffering can be alleviated – the keystone of the act,” she said.

“This is a weakening of the due process of the act and suggests that the ‘safeguards’ are seen more as a barrier to be overcome than an opportunity to improve life to the extent that euthanasia is no longer necessary.”

Colyer was reporting, and Best was providing commentary on a study of assisted dying practice in Belgium recently published in the Canadian Medical Association Journal (link is external).

Dr Best selects one factoid (the increase in second-opinions from GPs)—and claims there’s been a reduction in palliative care referrals—to argue a case that Belgium’s is a risky model.

And she’s absolutely wrong.

In the detail of the report (where you have to look to find the mention of GP second-opinions which she reports correctly), is also the clear statement that:

“…the proportion of cases in which at least one palliative care team was consulted about the request increased [with high statistical significance].”

But you don’t even have to read the whole report from cover to cover to find that out, even assuming that you had access to the full report—it’s behind a subscription paywall. Right there on ‘the cover of the tin’ (the publicly-available Abstract), it says in plain English that:

“Palliative care teams were increasingly often consulted about euthanasia requests, beyond the legal requirements to do so [with high statistical significance]” and “palliative care teams were increasingly consulted about the euthanasia request” [at least in respect of Flemish cases]

So, while Dr Best claims the study reported a “reduction in referral to palliative care doctors” the study itself says the exact opposite in multiple places: “palliative care teams were increasingly often consulted.” While Dr Best claims “a weakening of the due process of the Act”, the evidence in regard to palliative consults demonstrates the opposite: “a strengthening of the due process of the Act.”

Is this another example of the religiously opposed noticing ‘evidence’ that apparently supports their stance while failing to notice solid evidence (and in this case in a sentence immediately adjacent to the selected one) that contradicts that stance?

I have no doubt that Dr Best is an excellent palliative care practitioner, but in this matter she is utterly and evidentially wrong—and the evidence was anything but ‘buried’ in the report on which she chose to provide ‘expert’ commentary.

I ask the AMA to add an addendum to the article on their website, correcting the erroneous statement that there was a “reduction in referral to palliative care doctors.”

From the editor of MJA InSight:
Just to clarify for Rosemary Jones … MJA InSight content is not AMA content. We are editorially independent from the AMA and the AMA does not influence our content and editorial decisions in any way, shape or form … Thanks.
Cate Swannell

In response to Rosemary Jones, there are two findings related to the involvement of palliative care doctors in the study. First, the study found palliative care physicians were less likely to be the legally-required “second doctor” to sign off on the decision for euthanasia, as more GPs took on the role. Second, and as Sarah Edelman is quoted saying, 39% of patients had contact with palliative care teams in the lead up to euthanasia (but these doctors were not necessarily involved in sign-off). Although this latter figure is an increase from 33%, the article makes clear that this is more about palliative care doctors being “notified” than necessarily having any professional input into the decision-making process. Although Dr Edelman and the study authors said this was a positive development, Dr Best and another respected palliative care doctor who provided background for the article said it was still overall a very low rate of palliative care involvement.

I find it frustrating that people argue that folks argue for the “right” of those suffering intractable physical symptoms to suicide yet argue against that same “right” for those suffering intractable psychological symptoms. One cannot logically support the one and not the other. My concern, as a doctor, is that my “assistance” in the suicide process will somehow be coerced, either by change to the law to define physician-assisted suicide as the standard of care, or simply by advocates calling me cruel, uncaring or inhumane for refusing to kill somebody.

I agree that a Palliative Care Consultant should be involved in the decision making process but they must be open to the option of euthanasia. From the current writings on the topic we can see that many PCCs are against medically prescribed euthanasia. They need to acknowledge their moral ethical objection and not be allowed to participate in the process.
As for ‘lawyers’ and ‘polititians’ getting involved, I do not see that they would be helpful. A GP and a PCC have the skills and experience to make these decisions based upon the patient’s competent request. If the patient is fully informed and assessed as competent then who are we to stand in their pathway to a peaceful and dignified death?

In response to Mark O’Conner…by consulting a PCC who supports euthanasia presents the “flip side” of the issue you present of having a PCC open to the idea of euthanasia. You then have two people who are more than happy to support the person end their life. I much prefer the idea of lawyers and judges making the decisions with input from specialist medical consultants, PCC and patient GPs.